COVID-19, crises and fragility

 Fragile contexts are being hit by a new wave of the virus

Battling the coronavirus has become a global priority. In anticipation of a wave of global infection like that experienced by Asia, Europe and the United States, many of the most fragile contexts are already taking measures against the virus, including confinement. Since many fragile contexts remain outside the main global economic network the spread of the virus has been delayed for some of the most fragile and conflict-affected states (Figure 1). By mid-March, the most affected fragile contexts were the ones most connected with the world’s economy, such as Pakistan or Egypt (Covid-19 dashboard, 2020[1]). By early April, most fragile contexts were reporting cases, and extremely fragile contexts, notably those in conflict, are just starting to report their first cases?

 

Figure 1. Fragile contexts are affected later than other developing countries

Source: OECD (2020), States of Fragility Platform, http://www3.compareyourcountry.org/states-of-fragility/overview/0/

Fragile contexts reacted differently to the inevitable wave of outbreak in their countries. The most fragile contexts are facing difficulties to prepare, because of ill-adapted national health systems due to political and budgetary under-prioritisation and capacity constraints (OECD, 2018[2]). Some countries have strengthened control over communications about the government response, and independent reports about the spread of Covid-19 have been met with arrests (Atlantic Council, 2020[3]).

 Health systems are not able to absorb shocks in most fragile contexts

In most fragile contexts, health systems are weak and would be unable to cope with a Covid-19 outbreak of the magnitude seen in Asia, Europe, or the United States. Of the 34 African contexts surveyed in the WHO Covid-19 readiness status report, only 10 reported adequate capacity to respond to the epidemic (WHO, 2020[4]), including with protective equipment for the population. According to the WHO, a well-functioning healthcare system requires a steady financing mechanism, a properly trained and adequately paid workforce, well-maintained facilities, and access to reliable information on which to base decisions (WHO, 2010[5]). Most of those elements are missing in fragile contexts. Furthermore, health facilities are often concentrated in capital or major cities, and essential drug supplies are lacking. Even when fragile contexts spend a relatively large proportion of gross domestic product (GDP) on health, the proportion of doctors and hospital beds often remains exceptionally low (see Afghanistan, Table 1). Conflict-affected countries are facing dire situations. Health infrastructure and personnel are directly targeted in many modern conflicts, further restricting health care capacity (ICRC, 2016[6]). This leaves the population in those countries unable to cope with a health crisis amid conflict and displacement.

The pandemic also restricts the delivery of humanitarian aid in conflict-affected countries. The banning of flights has seen international relief scaled down to essential activities with limited international staff, and restrictions on entry to newly arriving or returning foreign aid workers. Increasing stigmatisation of expatriate aid workers and foreign NGOs in places like Bangui is also leading to a more hostile aid delivery environment (The New Humanitarian, 2020[7]). Medical evacuations have been halted, and global refugee settlements have been put on hold (UNHCR, 2020[8]) making forcibly displaced people particularly vulnerable. (OECD, 2020[9])

The pandemic also directly links health with other public services such as water and sanitation, with only 38% of people in fragile or conflict‑affected contexts having access to basic handwashing facilities at home (World Bank, 2017[10]). This makes personal protection and hygiene measures particularly difficult to put in place.

 Covid-19 response requires hospital equipment, but the most vulnerable do not have access to hospitals

Hospitals represent the highest level in country’s health systems and they account for the majority of medical doctors, equipment, and the biggest share of the health budget in fragile contexts. However, hospitals and health care are concentrated in capitals and most of the population in fragile contexts live in rural and peripheral urban areas, meaning they have no physical or financial access to hospitals.

Most vulnerable people rely on primary care structures to access the health system. Given the lack of medical doctors (Table 1), these health posts are often managed by nurses and community health workers, or by humanitarian workers. In the most fragile contexts where roads are scarce, there is often no capacity to refer patients from rural health posts to hospitals. In fragile contexts, most of the morbidity and mortality from preventable diseases is registered at peripheral centres. People die at home, not in hospitals, which partly explains the low number of reported cases in fragile contexts so far. As a result, fragile contexts experience a severe lack of coping capacity in terms of general health infrastructure, other public services such as water and sanitation, and poor extra capacity to cope with an epidemic (EC INFORM, 2020[11]).

For DAC donors, long-term support to the health systems in fragile contexts should take the whole health environment into account – including medical schools, logistics and supplies – with a strategic focus on primary healthcare.

 The pandemic highlights and deepens social inequalities

As with all disasters and crises, COVID-19 is revealing existing social inequalities. The impact of crises is greater on the poorest, and poverty is increasingly concentrated in fragile and conflict-affected contexts. Social distancing is often seen as the best way to curb the rate of infection, and as of 4 April, the governments of all 58 fragile contexts have implemented some measures to curb the spread of COVID-19. This includes partial or full lockdowns in 19 of the fragile contexts (ACAPS, 2020[12]). However, the feasibility of such confinement measures is unlikely to be applicable in fragile contexts. Around 1 billion people live in slums and populous suburbs in developing countries, including in fragile contexts (World Bank, 2019[13]). For most people living in those contexts their livelihood is dependent on the informal economy, meaning confinement measures will likely have a devastating effect on their ability to make a living. To a larger degree they live day-to-day; the poorest are unable to stock food and other essential goods even for a few days. The poorest people, relying on the informal economy, have to balance between the risk of infection if they venture out to earn daily income and the certainty of food shortages if they keep confined.

 Reinforcing health systems alone is not possible

The implications of the crisis go far beyond health systems. Health systems in fragile contexts are not weak in isolation. Different dimensions of fragility amplify its weakness. Covid-19 pandemics highlight the multi-dimensional aspect of fragility, and highlight the importance of building system resilience across all dimensions of fragility. A resilient health system requires resilient country systems. It requires appropriate governance, trust and respect from the population, and sound economic management.

 

Figure 2. ODA investment in health system in fragile contexts

Source: OECD (2020), States of Fragility Platform, http://www3.compareyourcountry.org/states-of-fragility/Covid/0

In many fragile contexts, the health sector has not been prioritised, and represents a small share of the national budget, with domestic general government health expenditure amounting to 1.3% of GDP across the World Bank fragile and conflict-affected grouping, compared to 7.4% worldwide (World Bank, 2020[14]). International support is important in fragile contexts, but ODA to health sectors in fragile contexts has not increased since 2013 (Figure 2). Support is primarily channelled through the public sector (Figure 3), but it has not translated into more effective health services for the population in fragile contexts. It has not compensated for the population increase over the last decades and the corresponding need for health services.

A large part of ODA to the health sector in fragile contexts is channelled through the multilateral system and NGOs, in particular humanitarian health assistance. Global humanitarian assistance from OECD DAC donors represents 24% of ODA to fragile contexts in 2018 (OECD, 2020[15]). The primary focus of humanitarian actors is to save lives, not to reinforce national health care systems. However, in the most remote areas of many fragile contexts they are the only health providers.

 

Figure 3. ODA to the health sector to fragile contexts by channel, 2018

Note : 2018 share reflects trends in previous years.

Source: Calculations based on the OECD (2020), Creditor Reporting System, https://stats.oecd.org/

 Securitisation and law enforcement is an additional risk for the most vulnerable

To contain the outbreak, many national governments have started pairing their medical resources with law enforcement. Police abuse has already been reported in several contexts that have imposed confinement measures (HRW, 2020[16]). Security sector capabilities are also mobilised, notably to enforce lockdown. Recent Ebola outbreaks have shown that such deployments can exacerbate tensions, especially in countries where security forces face high levels of public distrust. In addition, in some areas where humanitarian workers are providing the bulk of medical services, the association of health providers with a mistrustful military force can raise concerns. Because of the insecurity in eastern Democratic Republic of the Congo, the Congolese army, the FARDC, escorted some health workers responding to the Ebola outbreak. Because the FARDC’s record of abuse (HRW, 2009[17]), people were hiding cases instead of going to clinics, and health workers responding to the Ebola outbreak were attacked (Reliefweb, 2019[18]). DAC members supporting security sector reform (SSR) could ensure that security and law enforcement curricula include protection and international humanitarian law elements, propagating that the civilian population is not an enemy, and ensure that abuses are reported and punished. This requires coherence and consistency across partner’s support of SSR (OECD, 2008[19]).

 COVID-19 diplomacy

As is the case with many large-scale natural disasters, Covid-19 is an opportunity for countries to shape, or try to re-shape, diplomatic relations. New donors are stepping up their humanitarian operations in Africa (International Crisis Group, 2020[20]). Crises can also ease tense relations between countries. Already, the United Arab Emirates (Al-Monitor, 2020[21]) and Kuwait have offered humanitarian assistance to the Islamic Republic of Iran. Taking on the UN call for a global ceasefire amidst coronavirus, a ceasefire has been reached in the Philippines (India Today, 2020[22]). Similar truces are being discussed in Colombia and Cameroon as well. COVID-19 could thus also be a peace opportunity. DAC members should be prepared to build on those ceasefires to help strengthen peace when the pandemic recedes.

Despite these efforts, diplomatic work is curtailed by the pandemic. UN special envoys have stopped travelling, and several mediating initiatives, including in the Bolivarian Republic of Venezuela, have been cancelled due to risk of contagion. International political leadership is now geared towards tackling the crisis. For example, meetings between diplomats in Yemen and the senior Saudi officials are being cancelled, and the EU-G5 Sahel summit has been postponed. While most diplomatic action has subsided, those who can should refocus their diplomatic action aiming to contain COVID-19 in co-operation with those in fragile contexts who need it most.

 Peacekeeping missions are also affected

Many issues that were important before the coronavirus outbreak are now given second priority. Wars in Yemen, Syrian Arab Republic, Libya and elsewhere are still being fought, and the urgency to address and stall these situations is even more pressing as COVID-19 propagates in these context. At the same time, the pandemic is limiting the international community’s capacity to support peace efforts across the world, as several peacekeeping missions are entering into a force protection mode, severely limiting operational activities (Whats in Blue, 2020[23]).

The UN has asked contributing countries to delay rotation of peacekeepers across all missions. For some missions, it means that military and police personnel are stranded in the country, possibly much longer than original assignments. For some missions it might also mean personnel will be rotated out but not replaced because of regulations limiting the time of deployment. The European Union has also adapted their peace operations, scaling back activities such as its training of security forces and local outreach. The first cases identified with troops in the Barkhane forces early April is also likely to impact their ability to operate in the Sahel without certainty as to whether belligerent elements in places like Mali will restrict operation from their side.

 The link with governance

Governance systems all over the world, but in particular in fragile contexts, are coming under unprecedented stress. The effectiveness of governments to design and implement policy responses to the crisis and the level of public trust in government (Fukuyama, 2020[24]) are considered crucial to contain and push back the virus. These key factors are weak in fragile contexts and they are not amenable to quick fixes. This means that self-organising citizens, community groups, civil society organisations, and faith-based organisations will need to step in to lead and advocate for improved sanitary protective measures and livelihoods support to compensate for loss of income within their respective communities.

As much as the quality of governance influences the spread and containment of the epidemic, the latter is also likely to have an impact on governance systems. There is growing concern that Covid-19 will accelerate the ongoing worldwide trend towards more autocratic governance, taking the opportunity to increase executive authority and citizen control, by restricting civic and political rights and freedoms. These measures, often taken under the auspices of states of emergency, may not be fully reversed when the crisis is over and could have a longer term impact of the prospects for democratic governance and citizen engagement (Green, 2020[25]). One out of six fragile states, for example, has elections scheduled in 2020 (IFES, 2020[26]). In some cases (e.g. Ethiopia and Gambia), these constitute critical junctures in vulnerable transitions towards more democratic governance that now risk losing momentum and legitimacy.

 The pandemic is not only a humanitarian crisis, but humanitarian needs will increase

The impact of the crisis is greatest on the furthest behind, especially those relying on humanitarian assistance. Refugee populations are often left out of disaster and epidemic preparedness planning. (OECD, forthcoming). National response plans must include efforts to reach marginalised refugees and migrants to ensure full inclusion and avoid stigmatisation. As national health systems collapse and poverty increases because of a lack of income and social protection, people will have to resort more to humanitarian health assistance in order to support or substitute defaulting peripheral health systems. However, with limited movement, restricted access, and closing borders, humanitarian operations are impacted. Important adaptations to humanitarian programmes have become necessary to ensure a minimum level of continuation (ACAPS, 2020[27]). In contrast with previous epidemic response, the international humanitarian personnel are now seen as vectors of transmission the virus and are subject to mistrust. The pandemic should therefore be an opportunity to guide efforts to localise aid further. This will require giving national humanitarian responders genuine operational and financial ownership and responsibilities, in line with the paradigmatic shift called for at the 2016 World Humanitarian Summit.

 As ODA is re-oriented toward Covid-19, tackling the root causes of fragility should be safeguarded

Countries are better able to cope with a crisis such as the Covid-19 pandemic when they are resilient, and when the country systems are functioning well. In times of crisis, populations look towards their leaders for response. The lack of trust between government and the population is a driver of fragility and a characteristic of fragile contexts (OECD, 2018[2]). As a result, addressing fragility as a whole should remain or become a priority focus of DAC members’ engagement in fragile contexts, so that countries are better able to face future risks using their own national resources. Fragility cut across economic, environmental, political, security, and societal dimensions (OECD, 2020[15]), and all those dimensions are important to help countries build a strengthened health system that is available and affordable to all.

The delay in Covid-19 reaching fragile contexts has allowed some time for the humanitarian and development sector to re-orient itself in the response. On top of global pledges from the main bilateral and multilateral donors, some existing funds are redirected to the Covid-19 crisis. For example in Afghanistan, a contingency fund managed by the UN has allocated USD 1.5 million for Covid-19 preparedness. The UN Central Emergency Response Fund (CERF) has set apart funds to help contain the pandemic. Current aid budgets and country strategies will have to be adjusted in the coming months as the pandemic evolves. With donors national finance being put under pressure by the pandemic at home, there is a risk that aid budgets will decrease, with a possible deterring impact on actions addressing the root causes of fragility.

 Addressing the economic impacts of COVID-19 will be critical to safeguard both countries’ financing situation, and their stability

While fragile contexts fared reasonably well during the global financial crisis, especially in Africa, many now face higher external debt, and have increased their linkages to the global economy and capital markets, which are now drying up (Ongley and Selassie, 2020[28]). As a result, the pandemic will likely have a significantly negative impact on the economic and financial resilience of fragile contexts, at a time when resources will come under strain. Many fragile contexts are heavily reliant on commodity exports and will suffer from the drop in commodity prices and global demand – especially from China, a main export market and a key source of manufacturing machinery. Developing countries will likely see a “flight to safety”, where investors reduce investments seen as risky in favour of safer assets. Such trends can reduce government finances, private investment, and household incomes, even while the need for social expenditure, healthcare, and economic stimulus grows.

Debt sustainability will likely be a key factor for fragile contexts. Public debt has increased steadily since the debt relief provided under the Heavily Indebted Poor Countries Initiative (HIPC) and the Multi-lateral Debt Relief Initiative (MDRI) (Figure 4) reducing the space that countries have to respond to the crisis. Of the low-income countries assessed at high risk or already in debt distress, all but three are either fragile contexts, small island developing states (SIDS), or both.1

 

Figure 4. Public debt in the most fragile contexts has increased steadily since HIPC

Central government debt as percentage of GDP, 2004-18

Note: 2018 Extremely fragile excludes Syrian Arab Republic and South Sudan due to data availability. Note that South Sudan is included in Sudan prior to 2012. Data gaps have been filled by using most recent available data.

Source: IMF (2020) Data Mapper, https://www.imf.org/external/datamapper/CG_DEBT_GDP@GDD/CHN/FRA/DEU/ITA/JPN/GBR/USA/IND; and OECD (2018) States of Fragility, https://www.oecd.org/dac/states-of-fragility-2018-9789264302075-en.htm

Economic resilience is a key coping mechanism in fragile contexts, by cushioning the impact on people and societies of shocks and crises. But few governments or households have the ability to introduce similar responses to those taken in Europe, and the private sector often has a large proportion of smaller, more informal and micro-enterprises, with less access to capital and safety nets.

To be effective, responses to Covid-19 will need to include sufficient attention to addressing economic impacts at the macro and micro level, and address debt sustainability over the medium term. As outlined in the forthcoming OECD brief A “debt standstill” for the poorest countries: How much is at stake?, in the short term fragile contexts will benefit significantly from the G20-negotiated moratorium on debt service payments2, delaying these obligations until 2021 and freeing much-needed liquidity to cope with the immediate impacts of COVID-19 (OECD, forthcoming[29]).

 A commitment for long-term engagement is needed, focused on human capital

Addressing fragility is a long endeavour, and donors will only be effective if they support processes that come from within. Objectives such as reinforcing all components of a country’s health systems takes decades to be reached, and touches upon all dimension of fragility. After the 2015 Ebola outbreak in West Africa, pledges to build back more resilient health systems did not translate into long-term engagement. The “Ebola effect” - or increased funding because of the outbreak – had ended in the three countries affected by the epidemic by 2015 (Figure 5). In 2018, Humanitarian funding has dropped by 77% in these countries and for the most part has not been offset by development funding, which dropped globally by 17% between 2015 and 2018.

 

Figure 5. ODA in Guinea, Liberia, Sierra Leone

Source: Calculations based on the OECD (2020), Creditor Reporting System, https://stats.oecd.org/

From DAC members, only a long-term commitment to address all dimensions of fragility can help these contexts address risks contributing to fragility across dimensions and ultimately increase resilience against crises in the future. Building back better also requires investing in people. Through nutrition, health care, and quality education, people accumulate knowledge, skills, and health throughout their lives, enabling them to realise their potential as productive members of inclusive and resilient societies.